Regulatory investigations reveal systemic failures among Commercial California Health Plans in delivering timely behavioral health care
The California Department of Managed Health Care (DMHC) identified 70 Knox-Keene Act violations and 35 barriers to care across 14 commercial health plans. These behavioral health investigations, covering three of five completed phases, reveal industry-wide failures in providing mental health and substance use disorder services to enrollees.
Why are California health plans facing behavioral health violations?
The California legislature mandated these behavioral health investigations (BHIs) in 2020. The DMHC uses them to determine if enrollees in licensed plans can access the care they are entitled to under state law.
The process involves reviewing plan data and interviewing providers, staff, and enrollees. These investigations target full-service commercial plans but exclude Medi-Cal, Medicare, and self-insured plans.
What specific failures did the DMHC identify?
The DMHC found consistent violations across 14 national, regional, and county-based plans. In Phase 1, 21 violations were found across five plans; Phase 2 saw 10 violations across four plans; and Phase 3 identified 39 violations across five plans.
Quality assurance failures appeared in 11 of 14 plans, including incompetent customer service and a failure to act on care quality issues. Ten of 14 plans violated timely access standards, often due to inaccurate provider directories or an inability to secure timely treatment.
Nine of 14 plans failed regarding grievances and appeals. According to the investigation, these plans failed to log or respond to enrollee complaints, leaving issues unresolved.
How do cultural competency gaps affect patient care?
The DMHC identified 35 total barriers to care, which are practices that hinder access but do not reach the level of legal violations. Cultural competency gaps were the most frequent, appearing in nine of 14 plans.
Most plans lacked programs to address disparities based on race, ethnicity, gender identity, sexual orientation, income, and geography. This lack of oversight is likely to affect LGBTQI+ and BIPOC populations, who face higher rates of mental health conditions.
The DMHC noted that these gaps can lead to diagnostic errors, negative medication responses, and harmful treatment interactions.
What happens next for these health plans?
Plans with violations have responded with corrective action plans (CAPs). These include updated policies, new monitoring processes, vendor changes, and increased staff training.
The DMHC could conduct annual follow-up reviews to ensure CAPs are fully implemented and improve access. The agency may also use these findings to enforce comprehensive cultural competency requirements across all regulated plans rather than addressing them one by one.
Enrollees struggling with care can file complaints via the DMHC Health Center at 1-888-466-219 or HealthHelp.ca.gov. The Health Consumer Alliance also provides free assistance to resolve plan problems.
Frequently Asked Questions
Which health plans are included in these investigations?
The BHIs cover full-service commercial health plans regulated by the DMHC. They do not include Medicare, Medi-Cal, or self-insured plans.
What is the difference between a Knox-Keene Act violation and a barrier to care?
A Knox-Keene Act violation is a breach of California law referred to the Office of Enforcement. A barrier to care is a practice that makes accessing care harder but does not rise to the level of a legal violation.
What were the most common legal violations found?
The most widespread violations were quality assurance (11 of 14 plans), appointment availability and timely access (10 of 14 plans), and grievances and appeals (9 of 14 plans).
Do you feel your health plan provides adequate access to mental health services?